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A nurse is caring for a 30-year-old client who was brought to the emergency department (ED).

Exhibits

The nurse should determine the assessment findings are consistent with which of the following disease processes?

For each assessment finding, click to specify if the finding is consistent with bacterial meningitis or encephalitis. Each finding may support more than 1 disease process.

A.

WBC count in CSF

B.

Muscle weakness

C.

Altered level of consciousness

D.

Kernig sign result

E.

Body temperature at 2105

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

A high white blood cell (WBC) count in cerebrospinal fluid (CSF) is more commonly associated with bacterial meningitis, characterized by a high neutrophil count, low glucose, and high protein levels. it is also seen in encephalitis and reflects the individual cell lines that are affected.

Muscle weakness and altered levels of consciousness can occur in both conditions but are more prominent in encephalitis, which often presents with focal neurological deficits and seizures. The

Kernig sign, a classical sign of meningitis, is a physical examination finding that indicates irritation of the meninges and supports a diagnosis of bacterial meningitis when positive.

An elevated body temperature is common in bacterial meningitis, but it is not exclusive and can be observed in encephalitis as well.


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Related Questions

Correct Answer is D

Explanation

A. Placing the client on a ventilator to remove CO2 is not directly related to preventing the development of MODS. While ventilation might be necessary for respiratory support, it does not address the systemic infection and inflammation that contribute to MODS.
B. Advising the client to use their call light to reduce the risk of falls is important for general safety but does not address the critical factors involved in preventing MODS in the context of SIRS.
C. Providing a high protein diet can support overall nutrition and healing but is not the primary intervention for preventing MODS. Managing the infection and maintaining hemodynamic stability are more critical.
D. Administering antibiotics to treat the bacterial infection and maintaining a mean arterial pressure (MAP) of at least 65 mm Hg are essential interventions. Effective antibiotic therapy addresses the infection, and maintaining MAP ensures adequate organ perfusion, both of which help prevent the progression to MODS.

Correct Answer is D

Explanation

A. DKA occurs due to a significant deficiency of insulin rather than issues with cell response to insulin. The condition leads to high blood glucose and ketone production because there is not enough insulin to regulate glucose levels effectively.
B. DKA is primarily associated with diabetes mellitus type 1, not type 2. It can occur due to a lack of insulin and is not solely caused by illness, although illness can exacerbate it.
C. DKA is not limited to clients with diabetes mellitus type 1 who experience septic shock. It can occur in anyone with type 1 diabetes due to severe insulin deficiency, though septic shock can complicate the condition.
D. DKA results from a complete absence of insulin, which is characteristic of poorly controlled or undiagnosed diabetes mellitus type 1. This insulin deficiency leads to elevated blood glucose levels and ketone formation.

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